DSM makeover: What will they come up with next?

Overhaul of diagnostic bible shrouded in secrecy

It's a tried-and-true formula:

1. Do a quick-and-dirty study or two.

2. Find a huge, perhaps escalating, problem that has heretofore been overlooked.

3. Create a product label (aka diagnosis).

And, voila! The drug companies will take it from there. A diagnosis that was once just a twinkle in the eye of a creative researcher becomes reified as a concrete entity.

Over the past couple of decades, the DSM has risen from its humble origin to an object of worship, regarded as the absolute scientific truth. Privately, however, many mental health professionals refer to it as a "joke." That's partly because we are aware of studies showing the poor validity of many of its constructs. It's also because we know about some of the forces (in addition to scientific progress) that influence each new edition. These include internal turf wars (the DSM-III was developed in large part to decrease the power of the psychoanalytic wing of psychiatry), cultural fads, group-think, and outside lobbying. And leading the outside lobbying, of course, is the pharmaceutical industry.

An example of how this process works is the case of shyness. Christopher Lane, an English professor and Guggenheim fellow, shows in his book, Shyness: How Normal Behavior Became a Sickness, how psychiatrists transformed shyness from a normal personality trait into a pathological condition labeled Social Anxiety Disorder. As Lane points out, not only can diagnoses be manufactured out of whole cloth, but their prevalence can be made to rise and fall like the stock market through arbitrary adjustments of the threshold cutoffs. And the DSM has a very low bar for calling something a disorder.

In writing his book, Lane was able to get unprecedented access to internal memos and letters of the American Psychiatric Association's DSM-III task force. Based on these primary sources, he credits the rise of the DSM from an obscure tract used mainly by state hospital hacks to an international bible to one man - Robert Spitzer - who chaired the task force and handpicked its members from people he considered "kindred spirits." (Spitzer is perhaps better known among the general public for his controversial stance that gay people could be turned heterosexual through reparative therapy.)

Over the years, the DSM has expanded from just 106 pages to its current 886. (See chart.) The severe mental disorders that once formed the book's core are still in there. There's just so much fluff that it's harder to find them.

And now, the American Psychiatric Association is at it again, working on the fifth edition that is set to launch in May 2012. But this time, perhaps in response to exposes such as Lane's, there will be no telltale memos and letters to document the process. Task force members are sworn to complete secrecy; they must sign a "confidentiality agreement" prohibiting them from disclosing anything to anyone.

Petition drive against secrecy

Ironically, even DSM-III architect Robert Spitzer is being excluded this time around. Denied access to task force committee minutes and other information, an angry Spitzer wrote a protest editorial that was rejected for publication by the American Journal of Psychiatry, the official journal of the American Psychiatric Association. (The editorial, "Developing DSM-V in Secret," is online here). With psychologist Scott Lilienfeld and others, Spitzer last month called for a petition drive to force the APA to open up the DSM-V revision process to public observation.

No doubt hoping to forestall such a petition drive, the APA just announced that its Assembly of local branch representatives will vote November 18 on an "action paper" that would encourage less secrecy. The vaguely worded paper calls on the APA's Board of Trustees to "develop policies and processes that balance the need for openness and transparency and the need to protect its intellectual property." If approved by the Assembly, the action paper will go before the association's Board of Trustees in December.

The secrecy issue comes amid mounting controversy over psychiatrists' ties to the drug industry. The U.S. Senate Finance Committee has launched an investigation into whether drug money is compromising the integrity of medical science. Prominent psychiatrist Charles Nemeroff of Emory University, whom critics have nicknamed "Dr. Bling Bling," is at the center of the probe; he reportedly earned millions of dollars from pharmaceutical companies while promoting drugs to heal depression and other emotional problems. (See Sunday's Atlanta Journal-Constitution.)

Perhaps all of this hubbub will encourage the DSM developers to be a bit more circumspect with new diagnoses, realizing that a massively overmedicated and increasingly cynical public could get fed up.

Perhaps the DSM's stranglehold on diagnosis would not be so serious if the book were only being used for its original and stated purpose, as a tool to help clinicians speak the same language in their efforts to understand and treat the mentally ill. But, increasingly, both medical and psychiatric disorders are being shaped by and for the pharmaceutical industry. (A good example of Big Pharma's influence over medical doctors is The rise of Viagra: How the little blue pill changed sex in America.) And in the forensic arena, the DSM is often employed pretextually, to accomplish various legal outcomes.

Proposed new diagnoses

So, what is in store this time around? Here's my sampling of some of the more controversial changes and new conditions being proposed, some with very specific relevance to forensic practice:

Parental Alienation Syndrome: This is by far the most controversial theory in high-conflict child custody litigation. And the battle lines are drawn primarily by gender: PAS is apt to be the first line of defense when a husband is accused in a custody battle of sexually abusing his children. Despite its lack of empirical support, a partisan lobby is pushing for its inclusion. (See my March 2008 blog post, "Showdown looming over controversial theory," for more background.)

Hebephilia: All psychodiagnoses, even those of psychotic disorders, have serious conceptual validity problems, but none are weaker than some of those being used to justify the civil commitment of sexually violent predators. The latest, and most farcical, is "hebephilia," or the sexual attraction to teens, which is being aggressively marketed by a small advocacy group. (I'll have more to say about this newly proposed diagnosis very soon; for now, you can check out my Halloween 2007 post, "Invasion of the hebephile hunters.")

Gender Identity Disorder: The proposed inclusion of this category has drawn the most fire, primarily from transgender activists, who have mounted a petition drive against Ken Zucker, chair of the sexual disorders task force. Information on this controversy can be found here, here, and here.

Among other novel constructs proposed for inclusion in the DSM-V are Internet Addiction and Relationship Disorder. If Big Pharma has its way, Female Sexual Dysfunction (FSD) could also be a contender (see my Amazon review of The Rise of Viagra). In addition, there are proposals to tweak the criteria for existing diagnoses relevant to forensic practice, including the sexual Paraphilias, Posttraumatic Stress Disorder, and Conduct Disorder.

For more information see:

Robert Spitzer’s documents criticizing the DSM-V secrecy (online here)

The APA’s official DSM-V website (here)

A critical analysis of psychodiagnosis more broadly (here)

My review of Christopher Lane's book, Shyness: How Normal Behavior Became a Sickness, is here. (As always, I encourage my readers and subscribers to click on the "yes" button if you find my Amazon reviews helpful; it helps get the word out.)

For further information on the pharmaceutical industry's role in the process, see my May 2008 blog post, "Who will write the next DSM?" and also check out my Amazon booklist, "Psychiatry and science: Critical perspectives."

Other academic articles on DSM diagnosis (not all of them available online, unfortunately) include:

Andreasen, N.C. (2007). DSM and the death of phenomenology in America: An example of unintended consequences. Schizophrenia Bulletin, 33, 108-112

Cunningham, M.D., & Reidy, T.J. (1998). Antisocial personality disorder and psychopathy: Diagnostic dilemmas in classifying patterns of antisocial behavior in sentencing evaluations. 16, 333-351.

Healy, D. Apr 15, 2006. The myth of 'mood stabilising' drugs. New Scientist (David Healy is a very controversial figure in this debate; Google his name for more on him)

Ruocco, A. (2005). Reevaluating the distinction between Axis I and Axis II disorders: The case of borderline personality disorder. Journal of Clinical Psychology, 61, 1509-1523

Stevens, G.F. (1993). Applying the Diagnosis Antisocial Personality to Imprisoned Offenders: Looking for Hay in a Haystack. Journal of Offender Rehabilitation, 19, 1-26

Tom Zander, Psy.D. (2005) Civil commitment without psychosis: The law's reliance on the weakest links in psychodiagnosis. Journal of Sex Offender Civil Commitment: Science and the Law (online here)

The photo of the DSM manuals is from the Bonkers Institute for Nearly Genuine Research, a very creative website.

Goldilocks and the 3 Bears

When the Bear family came home from an evening of foraging at the local Chinese buffet, Mama Bear noticed that someone had been eating in her kitchen.

"Who ate the crab cake and left the crumbs on the counter?" she asked.

"Not I," said Papa Bear.

"Not I," said Baby Bear.

Papa Bear went upstairs and saw that someone had been sleeping in his bed. In fact, that someone was still sleeping, curled up in Papa Bear's blanket on the bed, with his shoes, socks, and pants lying on the floor.

"Who's been sleeping in my bed?" Papa Bear asked.

No, wait a minute, scratch that. Modern bears have cell phones. So Papa Bear did not confront the intruder. Instead, he quietly crept downstairs, gathered up Mama Bear and Baby Bear, and went outside to call the police.

Goldilocks was still asleep when police rolled up.

"What are you doing in my house?" demanded the brazen, modern-day Goldilocks of police.

As it turns out, poor Goldilocks was a 50-year-old man who - with the recent economic downturn - had just lost his job. He was apparently so drunk that he entered the wrong bed in the wrong house. In fact, he got off the bus a full eight miles from his own home in Damascus, Maryland.

The drunken Goldilocks was apologetic.

"I'm so sorry. I'm so sorry," he told the Bears. "And by the way, you have a very comfortable bed."

The modern-day Bears were also a good deal more charitable than in the original tale.

Mama Bear, a middle school teacher named Joanne Breiner, packed up a container of homemade chicken soup, homemade cookies, and spareribs for Goldilocks.

"I think her mom would have been disappointed if we didn't feed the intruder," said Papa Bear (aka Bob Breiner).

In the modern saga, by the way, Baby Bear was 16 years old and had carelessly left the front door unlocked.

Police would not reveal Goldilocks' real name, saying only that he had no criminal record.

Why am I posting about Goldilock and the Bears?

Because in forensic psychology we sometimes get cases like this. Indeed, I had a case very similar to this one, except the Goldilocks in my case was arrested and prosecuted for burglary. In my case, Goldilocks had not been drinking; rather, he was sleepwalking while in an altered state due to an extremely high fever. His charges were dismissed based on witness accounts of his illness, medical records that substantiated his fever and lack of blood-alcohol, and his documented history of somnambulism (sleepwalking).

In the forensic context, the Diagnostic and Statistical Manual of Mental Disorders (DSM) cautions about the possibility of malingering - or faking - of such fugue-like states in order to avoid criminal responsibility.

"Criminal conduct that is bizarre or with little actual gain may be more consistent with a true dissociative disturbance," states the DSM-IV-TR.

That must have been what police concluded in Goldlilocks' case. Instead of arresting the embarrassed fellow, they released him to his wife. After all, most burglars don't just eat the crabcake and go to bed.

The Washington Post has the story.

Sex offender laws criminalizing children

Unintentional wrinkle in sex offender hysteria

A 15-year-old Ohio girl may have to register as a sex offender for the next 20 years – until she is 35 years old! - because she had the bad judgment to share with her friends some nude photos of herself that she took with her cell phone.

The girl's friends may also be charged in the case.

Under the federal Adam Walsh Act, which I blogged about yesterday, judges lost much of their ability to exercise common-sense discretion in cases like this. Instead, crimes must be punished based on fixed offense categories or "tiers."

The law under which the girl is charged makes it a 5th-degree felony to possess material showing a minor in a state of nudity. There is an exemption for parents or guardians who take nude photos of their own children, but no exemption for a child herself.

The legislator who wrote Ohio's Megan's Law, Republican Jay Hottinger, said this type of case was not what the legislature had in mind.

Maybe, instead of just thinking about getting votes, legislators should have been thinking a bit more carefully and deeply when they drafted all these laws, because this high school girl is far from a fluke.

As an expert on child pornography pointed out at a recent forensic psychology conference in Ireland, much of the sexually explicit imagery on the Internet is uploaded by the youngsters themselves, through such sites as Facebook, YouTube and Bebo; other images, as in this case, are sent from friend to friend via mobile phones.

Dr. Ethel Quayle, director of Europe's Combating Paedophile Information Networks in Europe (COPINE) and author of a book on Internet Child Pornography, estimated that about half of all online sexual solicitation involving children is done by the children themselves.

Dr. Quayle said the stereotype of middle-aged men grooming children for sexual exploitation is way off the mark; laws predicated on this bogeyman image are resulting in the increased criminalization of children like the Ohio girl.

The Newark (Ohio) Advocate has more on the Ohio case. The Irish Examiner reported on the forensic conference at University College Cork in Ireland. Photo credit: Hialean (Creative Commons license).

Challenge to juvenile sex offender risk prediction

Harsh federal law on shaky scientific ground

Did you know that each year, about 10,000 children will have to register as sex offenders for life?

That's part of the Sex Offender Registration and Notification Act, embedded in the Adam Walsh Child Protection and Safety Act passed by the U.S. Congress two years ago. Under SORNA, these arrested juveniles will be subject to warrantless searches for the rest of their lives, despite the fact that as kids they did not have the same types of due process rights that protect adults in criminal court.

SORNA marks a huge departure from past juvenile justice practices, which recognized that children are different, and that most juvenile crime is "adolescent-limited."

So, here's some food for thought:

• What if it turns out that this new practice is not just extremely harsh, but paradoxically puts the public at heightened risk by impeding rehabilitation, and consigning kids who would otherwise move on with their lives to the status of permanent social pariahs?

• And what if it turns out that the "scientific" methods the states use to determine which juveniles are at high risk for sexual reoffending are completely worthless?

Well, it looks like both of those things are true.

Prediction tools don't work

This month's Psychology, Public Policy, and Law published an important study showing that the systems in place to determine which juveniles are at high risk for recidivism simply don't do the job.

The researchers followed high-risk juvenile males for an average of about six years. They rated them on the highly touted Juvenile Sex Offender Assessment Protocol (J-SOAP-II) and the risk protocols developed by three states (Texas, New Jersey, and Wisconsin). Not only did the systems not work, but they were not even consistent with each other!

"This finding suggests that a juvenile's assessed level of risk may be more dependent on the state he lives in than on his actual recidivism risk," the authors concluded.

And SORNA's own tiered risk system fared even worse: Juveniles designated as high risk actually recidivated at lower rates than others.

In summary, the researchers concluded that the risk tools that have such important implications for the lives and futures of adolescents are both "nonscientific" and "arbitrary."

Treatment works

Although the efficacy of sex offender treatment among adults is contested, among adolescents the study findings were clear: Developmental factors play a big role in adolescent sexual behavior, and risk for reoffense can be reduced through high-quality treatment.

This is consistent with other recent research showing that even the most intractable offenders can be rehabilitated -- and at a cost far lower than the cost of punishment.

The authors concluded that SORNA as it applies to youth is not only misguided but is likely to do more harm than good:

"The legislation … is based on the assumption that juvenile sex offenders are on a singular trajectory to becoming adult sexual offenders. This assumption is not supported by these results, is inconsistent with the fundamental purpose of the juvenile court, and may actually impede the rehabilitation of youth."

Now, consider these facts:

• Most juvenile sex offenders stop offending by early adulthood.

• Among delinquents, just as many non-sex offenders as sex offenders go on to engage in adult sexual offending.

• At least one in five adolescent males commits a sexual assault. (See Abbey, referenced below.)

What do these facts add up to?

The need for widescale prevention efforts, instead of ineffective stigmatization of a few unlucky individuals. (Funding for such efforts has dropped precipitously, probably not coincidentally to the rise of increasingly punitive sanctions; see Koss citation, below.)

Other challenges to SORNA

Meanwhile, other aspects of SORNA face challenges, and a few such challenges are headed for the U.S. Supreme Court. Specifically, legal challenges assert that SORNA exceeds federal rights by encroaching on state and local decision-making.

As summarized in the current issue of the American Bar Association journal, at least two courts have sided with critics and invalidated some or all of the registry law, and in a third case the new law has been put on hold until arguments are heard. (I reported on one of those cases, U.S. v. Waybright, back in August – the blog post with links is here.)

SORNA-style databases are already being extended to domestic violence offenders, and if they are upheld by the U.S. Supreme Court they are likely to extend even further. That is the conclusion of Wayne A. Logan, a law professor at Florida State University and author of the forthcoming book Knowledge as Power: A History of Criminal Registration Laws in America.

So, warn your kids now: Don't ever get arrested. You may be publicly stigmatized - and perhaps even subject to warrantless searches - for the rest of your life.

For further information:

Caldwell, M.F., Ziemke, M.H., & Vitacco, M.J. (2008). An examination of the Sex Offender Registration and Notification Act as applied to juveniles: Evaluating the ability to predict sexual recidivism. Psychology, Public Policy, and Law, 14 (2). 89-114.

Abbey, A. (2005). Lessons learned and unanswered questions about sexual assault perpetration. Journal of Interpersonal Violence, 20 (1). 39-42.

Koss, M.P. (2005). Empirically enhanced reflections on 20 years of rape research. Journal of Interpersonal Violence, 20 (1). 100-107.

For further information on the juvenile registration requirements of SORNA, see the U.S. Department of Justice's online fact sheet; this month's Police Chief magazine also has a summary of SORNA that includes the juvenile provisions (online here). The full text of the Adam Walsh Child Protection and Safety Act is here.

The American Bar Association article, "The National Pulse: Crime Registries Under Fire -- Adam Walsh Act mandates sex offender lists, but some say it's unconstitutional," is available here.

9th circuit upholds expert witness exclusion

Proposed testimony on murder victim's suicide risk

Jeffrey Moses' defense against the accusation that he murdered his wife Jennifer was that she shot herself to death. As evidence, he wanted to call Dr. Lawrence Wilson, a forensic psychiatrist and expert on suicide.

At a pretrial evidentiary hearing, Dr. Wilson said he would testify about Jennifer's depression and substance abuse. To counter the testimony of government witnesses who said she did not appear visibly depressed, he was prepared to opine that someone who is severely depressed can mask such feelings from friends and co-workers.

As law professor Colin Marshall summarized it over at the EvidenceProf Blog:

Dr. Wilson was also prepared to testify that several risk factors, such as depression, substance abuse, and access to firearms, heighten the risk of suicide. Additionally, he was prepared to testify that lay persons do not fully understand the implications of major depression and the connection between these various risk factors and suicide. Although Dr. Wilson was not willing to opine that Jennifer Moses committed suicide, he was prepared to testify that Jennifer Moses fell "into a group of people with an extreme number of severe and significant risk factors for suicide" and that "she continued to suffer [from] major depression...that continued to the time of her death."

The trial court excluded Dr. Wilson's testimony on the grounds that much of it was within the common knowledge of potential jurors, and was cumulative in light of other evidence that Jennifer did indeed suffer from depression. Also, Dr. Wilson's testimony that 15 percent of people with depression ultimately kill themselves was too prejudicial and potentially confusing to a jury, the trial court ruled.

The Washington state case is Moses v. Payne, 2008 WL 4192031 (9th Cir. 2008), available online here. The analysis by Professor Colin Miller from the John Marshall School of Law is here.

Odd twist in latest DNA exoneration

Speaking of movies -- here's a yarn that would make a good film plot:

A man named Clay Chabot is suspected of raping and killing a woman named Galua Crosby. He goes to trial. A key piece of evidence is the testimony of his brother-in-law. The brother-in-law, Gerald Pabst, testifies that Chabot forced him to tie up Mrs. Crosby and then ordered him out of the room; he could hear Ms. Crosby saying "no" before she was shot. With this kind of evidence, it is no surprise that Chabot is convicted. He gets life.

For the next two decades, Chabot insists he is innocent. He requests DNA testing to prove it. Finally, he gets his wish and - guess what - the incriminating DNA belongs to his good samaritan brother-in-law.

What makes the case all the more interesting is that the prosecutor, Janice Warder, had cut a secret deal with Pabst, promising him immunity from prosecution in exchange for his testimony. Considering his guilt, it was too good a deal to pass up.

And, since no bad deed goes unrewarded, the prosecutor went on to become a judge in Dallas County, Texas; she is now up for uncontested reelection as the District Attorney of Cooke County, Oklahoma.

For Dallas Morning News coverage on this case, see:

Former Dallas County prosecutor who withheld evidence will be Cooke County's District Attorney

Judge calls for retrial in 1986 slaying because of ex-prosecutor's misconduct

Jury convicts man of murder in 1986 Garland slaying

On an unrelated note, the Dallas Morning News also has a cool web page devoted to the Dallas Police Department's cold-case squad and some of its more interesting unsolved cases. Check it out; it's better than the TV series by the same name.

Hat tip: Grits for Breakfast